Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?
Session Report 489

Background and Objectives
Many low- and middle-income countries are not on
track to achieve the Millennium Development Goals
(MDGs) by the 2015 target. For example, only 23 are
estimated to be on track to achieve the 75% maternal
mortality reduction. This failure is primarily because
health-care interventions that are known to save lives
are not being implemented for every patient every
time they are needed. A gap exists between what
is known to work and improve health-care quality
and safety and what is being practiced routinely.
Fortunately, we have good evidence of how to address
this critical gap.
With this impetus, our session on ‘Making Health Care Better in Low and Middle
Income Economies: What are the next steps and how do you get there?’ was
convened at Schloss Leopoldskron from 22–27 April 2012, to chart the way forward
for improving health care. Our lead partner was University Research Co.,LLC
(URC), together with the support of USAID, the WHO Patient Safety Program,the
Institute for Healthcare Improvement),the University of North Carolina, Heidelberg
University and HealthQual/NYAIDS Institute. At the session we brought together
58 health leaders from 33 countries to review experiences in improving the quality
and safety of health-care services in low- and middle-income countries, synthesize
lessons learned from those experiences, discuss challenges and opportunities and
recommend next steps to stimulate improvement in such countries.
The seminar identified five interconnected priority challenges in improving quality
and safety in health care. The first is the ‘inadequate numbers of competent health
care workers’, which is worse in rural areas and in countries subject to internal and
international brain drains. Health-care workers lack needed skills due to inadequate
initial training, transfers and unmet training needs. These factors, and others, lead
to low staff morale that in turn increases the challenge to improve quality and
safety. The second challenge—recognizing and addressing different perceptions of
quality among providers, policymakers and the public—requires open dialog and
leads to the third challenge, ‘engagement of civil society’. Without an engaged
civil society, public protection and client focus are reduced. (This includes users
of health-care systems who are not patients. For example, pregnant women who
are delivering in healthcare facilities are users not patients.) This results in our
fourth challenge, ‘systems not designed to meet patient needs’, with many health

John Lotherington

05

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?
Session Report 489

programs established as vertical, poorly integrated activities in the health system.
This leads to our fifth challenge ‘poor health sector planning’, which encompasses
lack of comprehensive operational plans, poor integration of vertical programs into
health systems and inadequate harmonization of donor programs.
At the session we facilitated cross-border learning to address these challenges and
compared best practice in overcoming them, drawing on the immense experience
from the 33 countries represented. We then synthesized this learning into a call for
action, the Salzburg Statement: Better Care for All – Call to Action’, presented at the
World Health Organization’s (WHO) 65th World Health Assembly on 23rd May 2012.
M. Rashad Masood

Key Questions
The session’s key over-arching questions were:
•
What has worked to date in improving health care in low and middle income
countries?
•
How far has such improvement plateaued in the last decade?
•
How can we mobilize an upward curve in improvement of both patient and
population outcomes? What are the learning tools required?
•
How can we clarify the terminology, the methodology and the interpretation of
results in the field to avoid confusion which can undermine the dissemination
of good practice?
•
How does quality improvement mesh with other elements in health systems
strengthening, such as financial support, reform of governance structures, and
the mobilization of civil society?
•
What is the best way of introducing systems thinking and quality improvement
to countries which do not have a tradition of using these methods?
•
How do we move from small scale pilots to large scale improvement projects,
designing for scale and sustainability from the outset?

Bruce Agins

06

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?
Session Report 489

Better Care for All, Every Time
Louise Hallman

Editor, Salzburg Global Seminar

An translated version of this article appeared in Chinese Social Sciences Today, July 2012

In September 2000, world leaders gathered in New York to sign into being the
Millennium Development Goals. Focussing on such aims as eradicating world hunger,
reducing infant mortality, improving maternal health, and combating the spread of
HIV/AIDS, the MDGs set ambitious targets to be met by the year 2015.
Since that historic assembly, significant improvements have been made in global health
and welfare; however, three years away from the end date, many resource-constrained
lower- and middle-income countries are far from being on track to meet their MDGs.
For example, currently, only 23 countries are estimated to be on track for achieving
the 75% maternal mortality reduction goal by 2015. Whatever progress that had been
made, now appears to have reached a plateau.
So what do these countries need to be able to make better progress in health care and
reach their MDGs? More money, more resources, more hospitals, more doctors? Not
necessarily, claim an international group of health care experts.
Against this backdrop of stalled progress in global health care, 58 leading doctors,
researchers and health ministry workers met at the Salzburg Global Seminar – a

Pierre Barker

Fellows of session 489 - ‘Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?’

James Heiby

07

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?
Session Report 489

unique international institution committed to bringing industry leaders together to
find creative solutions to global problems – in Salzburg, Austria, for a session entitled
‘Making Health Care Better in Low and Middle Income Economies: What are the
next steps and how do we get there?’. Their conclusions from the intense week of
discussions were published as the ‘Salzburg Statement: Better Care for All – Call to
Action’ and presented at the World Health Organization’s (WHO) 65th World Health
Assembly on May 23.
So if money is not the solution, what do these ‘Salzburg Global Seminar Fellows’ suggest
in their Statement? The answer: quality improvement.
Speaking during the conference, Dr. M. Rashad Massoud, chairman of the Salzburg
session and Director of the US Agency for International Development (USAID) Health
Care Improvement Project (HCI), said: “Everything we’re talking about here is how can
we ensure the patients get the best outcomes possible. What is the best medicine that
we know? Can we deliver it to them correctly so that they benefit maximally from this?
Can we do this in ways that are not wasteful and inefficient? Can we be mindful about
meeting patients’ needs and expectations?

Edward Kelley

“Improvement is what we should be doing in the first place; good quality care is what
we should be providing patients anyway.”
But what does this mean in reality?
A money-focussed solution might suggest that the best way to improve maternal health
in Uganda (ranked 32nd worst maternal mortality rate in the world by the CIA World
Factbook) would be to train more midwives. But for many women in Uganda, their
Sheila Leatherman

08

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?
Session Report 489

tradition and culture stops them from ever seeing a midwife, regardless of how many
midwives there are.
“You are not allowed to say that you are pregnant,” explains Robinah Kaitiritimba, a
signatory to the Statement and Executive Director of the National Health Consumers’
Organization in Uganda. “So that means that women will not register with health care
givers. It is considered brave for a woman to give birth in alone in a room and not make
noise, even if she’s in pain.”
Nana Mensah-Abrampah

According to the Salzburg Fellows, the answer is to improve patients’ understanding
of the benefit of various forms of health care, not just simply to hire and train more
midwives and doctors; this is not only the responsibility of governments and their
ministries of health and education, or international donors and non-governmental
organizations, or the doctors and nurses who provide the health care, but also of the
patients themselves and the communities they live in, which is why they have been
included in this call to action.
Each of the seven stakeholders have their own several points of action; governments
must be “accountable for the improvement of health care through legislation,
policies and necessary resources”; health policy leaders should “adopt and promote
quality improvement as a cornerstone of better health care”; communities should
“actively advocate for quality health care as part of their rights and responsibilities”;
development partners and international donors are called to “invest in approaches that
drive sustainable context-specific improvements in global health”; NGOs and “those
providing technical assistance in global health” should “incorporate evidence-based
improvement methods in their work”; health care workers, not only doctors and nurses
but also all auxiliary staff are called to “continuously improve the delivery of expert and

Sylvia Sax

09

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?
Session Report 489

compassionate care to patients, their families and communities”; and finally, but just as
importantly according to the Statement’s authors, patients should “be empowered and
at the forefront of promoting a shared vision for better health for all”.
Lofty aspirations, but what makes this call to action any different from previous similar
efforts, like the WHO’s “Health for All by the Year 2000” or the MDGs?
“For one thing,” explains Lani Marquez, Dr. Massoud’s colleague and Knowledge
Management and Communication Director for USAID’s Health Care Improvement
Project, “the Salzburg Call to Action focuses on the how – what strategies and policies
can get us there.
“Quality improvement methods enable ordinary health workers to re-organize care
delivery processes. They provide a means to implement better practices and streamline
and change how care is delivered to yield better results with available resources. By
making changes in the current ways of delivering health care, rather than simply
adding more resources into dysfunctional systems, quality improvement methods
are about changing what we do with what we have – putting the knowledge and the
responsibility for improvement in the hands of every health worker, every patient,
every district health team, every program manager, and every policymaker.”
Even Marquez admits though, quality improvement, just like increased funds and
research, is no silver bullet.
By the time it was presented in Geneva on May 23, over 500 people from 65 countries
across the world, including China, had signed up to the Statement. But words and
signatures are nothing unless those called to action in the Statement do just that – act.
Louise Hallman

10

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?
Session Report 489

Making Health Care Better in Low and Middle
Income Economies: What are the next steps
and how do we get there?
Monday, April 23, 2012

Salzburg global seminar
SALZBURG DIARIES
Journey’s beginning
By: Ezequiel García-Elorrio
The opening remarks set the scene for
a spectacular session in a place where
solutions to global problems will be discussed and disseminated.
The history of the Schloss Leopoldskron and the Salzburg Global Seminar are
very impressive; since after World War II
this organization has promoted the gathering of people around the world to provide
solutions to global problems. The ambience is fantastic – it will surely make participants to give the most of themselves.
During the opening remarks goals were
set. The clearest one is to “set an agenda
of coming years”. Reviewing where we
are and how we got here. Constructing
then the action plan for the times to come.
Participants represented a wide variety of settings and realities from around
the world. So far just listening to everyone’s introductions you can perceive the
amount of experience and knowledge in
the room. Surely clear objectives and a
goal will come from this week-long discussion.
This week-long seminar is described as
the “beginning of a journey where we all
will go together” confirming that we are
“not sitting on plateau but moving ahead”.
The audience is quite diverse, comprising government, patient representatives,
international organizations, researchers
and improvers. Almost every point of
view is represented.
Just to give a sense on the importance
of our participation, the questions/debates
posted before the seminar were presented
to all participants to start the discussion.
Hopefully conversations from Salzburg
will reverberate around the world and
feedback could be provided.
Ezequiel García-Elorrio’s blog for
the ISQua Knowledge Portal can
be found online: http://www.isquaknowledge.org/activities/salzburg/
participate-during/

“Enormous potential”
Global healthcare professionals join
debate on quality improvement
By: Louise Hallman
Welcoming over 60 international
healthcare professionals from more
than 35 countries, Dr. M. Rashad
Massoud expressed his excitement at the
“wonderful journey” the participants
would take over the next six days at
Schloss Leopoldkron for the Salzburg
Global Seminar session ‘Health and
Healthcare Series IV: Making Health
Care Better in Low and Middle Income
Economies: What are the next steps
and how do we get there?’
The session has been two years in
the making, and will follow on from
previous sessions’ discussions to debate
the progress made so far in meeting such
targets as the Millennium Development
Goals and the role of quality improvement
in meeting such public health targets.
Whilst improvements in health care
have clearly been made in the past
number of years, this progress has since
“plateaued”, making it necessary for
health care professionals to address the
issues and challenges that still lie ahead.
Joining the “crucially important
meeting” via a pre-recorded video, Don
Berwick, former president and CEO of

the Institute for Healthcare Improvement,
USA, highlighted the great opportunity
such a global gathering of healthcare
experts would experience over the coming
week.
“In developed healthcare systems in the
Western developed world, we have a crust
to drill through,” he said.
“We have an existing legacy production
system that for complex reasons has
not been orientated around those six
aims [safety, effectiveness, patientcenteredness, timeliness, efficiency and
equity] for the continual improvement of
performance as its primary driver…
“I have the feeling that low and middle
income countries have a thinner crust.
There’s more opportunity there because
in some senses you’re building on a
relatively less developed platform of
management and process thinking. The
opportunity in lower and middle income
countries is to do it right the first time.
“I think the potential is enormous.”
A ‘Salzburg statement’, along with
several reports, will be produced at the end
of the week-long intensive discussions.
Don Berwick’s video will be
available on the “SalzburgSeminar”
YouTube channel.

Making Health Care Better in Low and Middle Income Economies:
What are the next steps and how do we get there?

Monday, April 23, 2012

Schloss Leopoldskron was built in 1736 by the Prince Archbishop of Salzburg, Leopold Anton Eleutherius Freiherr von Firmian. It was restored by reknowned theater director Max Reinherdt in the 1920s before being bought by
the Salzburg Global Seminar in 1959. It is overlooked by Festung Hohensalzburg, literally “High Salzburg Fortress”.

“

TALKING
P O I N T
Do we need
more data?
“

Work that is not
documented is not done, so
definitely documentation
would help to improve
quality - at then end the day
you have to be able to see
what you have done. There
are two issues: crediable
documentation and also
making documentation
easier... If we have this
system where you can plug in
the information at the time the
activity was going on, or at
worst at the close of the day,
then you cannot go back at
the end of month and change
the information for that day.
Charles Nde Awasom,
Medical Director, Ministry
of Health, Cameroon

”

There’s data for public
reporting purposes and
there’s data for actual clinical
management application. If
you connect the two, you have
a data source that serves two
purposes and is essentially
incredibly important to the
clinicians themselves... You
can’t improve something that
you know nothing about.
The vast majority of the
time [in my research] the
data element is collected and
sent somewhere on a district
level or a regional healthcare
system or government’s
national health system and the
clinic never learns how it’s
represented in public health
records.
Kedar Mate, Director for
Developing Countries
Programs, Institute for
Healthcare Improvement,
USA

”

“

It is helpful [to have
more data], but you can do a
lot without it, by sampling,

by rigorous independent
monitoring, particularly
of vaccination programs,
and having extensive
documentation, like a lot of
high income countries do,
doesn’t necessarily mean
that you use data more
intelligently.
Sir Liam Donaldson,
former Chief Medical
Officer, UK

”

“

It is true that in developing
country settings you do have
a lack of data...so for sure
documentation needs to be
improved, but it’s really about
what you do with it. In a lot of
countries there is tons of data
but it’s not developed with
clinicians in mind so it’s not
relevant and it’s not given to
them even if it were relevant
so they can do something
with it.
Ed Kelley, Head of
Strategic Programs,
WHO Patient Safety,
Switzerland

”

“

A lot of our problems
stem from inadequate
documentation but more
importantly, I think we
generate a lot of data that is
definitely not used optimally.
We don’t have adequate
information systems to
connect information at
community level. If you don’t
have a health information
system that works well across
all levels, you are losing out
a lot of vital information
that will enable you to put
interventions in place that are
going to target the community
best.
Nanthalile Mugala,
Director for Technical
Support, Integrated
Systems Strengthening
Program, Zambia

”

Got a question
you’d like to
have debated?
Tweet us!
@salzburgglobal

Making Health Care Better in Low and Middle
Income Economies: What are the next steps
and how do we get there?
Tuesday, April 24, 2012

Salzburg global seminar
SALZBURG DIARIES
Journey continued
By: Ezequiel García-Elorrio
James Heiby from USAID chaired
the Monday morning session where
key topics on the present situation of
Quality Improvement were discussed.
After a great warm up, ‘the knowledge
café’ began, with all participants rotating
among eight specific topic stations.
Experiences and thoughts were shared and
finally a facilitator per topic summarized
discussions and comments.
Key messages on lessons learnt were:
1. Widely available and simplified data is
critical for future QI in LMICs.
2. Cost effectiveness should be included
in the QI agenda, stating what should be
measured and how it should be done.
3. Organizational structures for quality
improvement at the different levels need
to be developed to promote capacity
building.
4. Knowledge dissemination constitutes
a challenge in terms of translation,
dissemination and the culture of sharing.
5. Scaling up needs commitment,
community involvement, planning and
standardized methods.
6. Leaders need to be involved from the
inception of the initiative and should receive economic arguments to “buy” interventions and programs, and finally should
facilitate the social society involvement.
7. QI methods can and must be applied
to processes in healthcare besides clinical
care, for example: logistics, human
resources and service management.
8. Research is critical to support improvement techniques although mixed methods
are needed to create a body of evidence
that could be of use for implementers and
decision makers. Evaluation also needs
a bigger space to disseminate findings
beyond the ones generated by research.
A great session and a great methodology. I believe this was an incredible way
to share experiences and to leverage an
already expert audience.

HR voted greatest challenge
Community involvement close second
By: Louise Hallman
Human resources – the lack and poor
use thereof – topped the healthcare
challenge chart, as voted for by
Salzburg Global Seminar session
participants yesterday afternoon.
Monday afternoon’s session, led by
Sheila Leatherman, Research Professor at
Gillings School of Global Public Health,
University of North Carolina, USA, saw
participants to split into groups to identify
challenges in two categories: how to
improve quality and how to improve
healthcare system delivery.
Heated debates arose as participants
reported back to the full room. Should
“patients’ needs” be added to “patients’
preferences”? Could the issue of staff
competency be considered in the same
human resources issue bracket as the
inadequate numbers of staff?
Once the participants – from such
wide-ranging backgrounds as physicians,
academics, government officials and
donors – had negotiated and agreed upon
the nuances of the challenges, they were
then asked to vote on what they believed
were the two greatest challenges they
faced in improving healthcare.
Coming out resoundingly on top
with 17 votes was human resources,

including but not limited to inadequate
numbers of health care workers, high
turnover, maldistribution geographically,
staff morale and unfilled training needs.
Community and civil society involvement
followed with 16 votes; this issue called
for more civil society engagement and
client-focus in advocacy, feedback, public
protection and responsiveness. In third
place was poor planning, encompassing
lack of comprehensive operational plans,
vertical programs that lack integration
and inadequate harmonization of donor
programs. Designing a system to meet
patient preferences and needs and
facilitating the process of addressing
different perceptions of quality among
providers, policymakers and the public
both garnered 12 votes.
Lagging behind were limited capacity
and capability to implement QI strategies –
7; leadership behavior – 6; involvement of
patients and staff in the process of improving
care – 6; absence of QI skills in the head
of frontline managers – 6; inadequate
information and poor communication – 6;
interface of strategy and implementation – 4;
optimization of technical skills – 3; poorly
articulated arguments to donors and decision
makers about the value of improvement
and the costs of poor health – 2; and finally
inadequate leadership with just one vote.

Making Health Care Better in Low and Middle Income Economies:
What are the next steps and how do we get there?

Tuesday, April 24, 2012

Prof. Sheila Leatherman hosted a “fishbowl discussion” as part of the session on Challenges Ahead. She
was joined by Cynthia Bannerman, Head of Quality, Department of Health, Uganda, Natalia Largaespada, Director
- Maternal and Child Health, Ministry of Health, Belize, Niaz Mohammad Popal, Ministry of Health, Afghanistan and
Robinah Kaitiritimba, Executive Director, National Health Consumers’ Organization, Uganda.

TALKING
P O I N T
Donors in
healthcare
One issue that was raised
in the day’s sessions was
that of the role of donors
in healthcare improvements. Several participants shared their views
with Planning Committee
Member Sylvia Sax.

“I don’t want donor money
because it has strings
attached.

”

“Donors want short term

solutions. When the money
is gone after two years, we
cannot continue the programs
put in place.

”

“

Donors come with their
own solutions and expect
them to be implemented.

An intrinsic part of what
donors are trying to do is
support the governments, not
to impose a specific agenda.
Intrinsically, improvement
has got to be owned by the
government, by the country
itself. And the solution is a
product of dialogue between
the donor and the country.
Jim Heiby, Medical
Officer and Contracting
Officer’s Technical
Representative, USAID
Health Care Improvement
Project, Washington, DC,
USA

”

“Anything we do needs to be

something that’s needed by
the government and that they
would like...
The role of the donor is
several fold: we can provide
resources, in the form of
money or in the form of
technical inputs. But we can
also use voice, often at a
global level to try and move
an entire sector a specific
way...
I think the best way we
can have an affect and
have impact is to support a
country’s leadership and to try
and leverage each other. We
shouldn’t be independently
investing here, there or
wherever. The whole needs to
be greater than the sum of its
parts...
So it’s about integrated
work, led by governments.
Mary Taylor, Senior
Program Officer, The
Bill and Melinda Gates
Foundation, Seattle,
USA

”

“

One of the important
things for donors is to know
the real situation of the
governments, or what is
going on in healthcare, what
priorities there are, what exact
problems there are, what the
priorities of the ministry of
health are. And then it’s very
important to communicate
with them and involve them
in the process from the
beginning...to help get them
on your side while you are
implementing something you
know will be good for them
and it will be easier to transfer
to them after you leave.
Shirin Kazimov, Health
Project Management
Specialist, USAID,
Azerbaijan

”

Who do you
agree with?
Carry on the
discussion.
Tweet us!
@salzburgglobal

Making Health Care Better in Low and Middle
Income Economies: What are the next steps
and how do we get there?
Wednesday, April 25, 2012

Salzburg global seminar
SALZBURG DIARIES
Confused.com
By: Ezequiel García-Elorrio
Silvia Sax from Heiderberg University
in Germany chaired the Tuesday
morning session on Overcoming
Issues of Confusion. Another highly
participatory methodology was used to
allow everyone’s opinion. Considering
the level of expertise in the room a
very interesting topic was brought to
discussion and much was said about
typical confusions when talking about
health care.
From brief presentations made by
participants from different regions of
the world, we could reflect on the fact
that the issue of confusion is keen to
everyone, given we all “suffer” from all
the contradictions and heterogeneous use
of terms.
I participated and witnessed very
lively discussions that were very fruitful
whenever producing conclusions. Below
you can read the topics discussed and some
issues of confusion:
Healthcare QI Terminology: naming
and concepts; differing models using
same fundamentals; problems when
implementing and using terminology.
QI Mechanisms: what are the different
mechanisms?; what works in each
setting?; role of technical assistance.
Whose role is to lead improvement in
healthcare quality?: government role:
ownership of initiatives and community;
role of donors: the advocacy issue.
Interpreting and acting on results: data
use for decision makers; use and report
of data using a common framework.
Overall the group set up a list of
recommendations (see ISQua Knowledge
Portal for the summary for the session)
that will help to construct the final
recommendations at the end of the week.
Many contributions were made and this
was maybe one the most difficult sessions
to narrow suggestions to a short and
prioritized list.

Participants vote on matters of confusion in healthcare improvement

SESSION OVERVIEW

Seventh and eighth blocks
Calls to expand “6 building blocks”
By: Louise Hallman
Participants the Salzburg Global
Seminar called on the WHO to expand
its “six building blocks of health
systems” in Tuesday afternoon’s QI
and Health Systems Strengthening
session.
Presented by Ed Kelley, Head of
Strategic Programmes and Coordinator,
WHO Patient Safety, Geneva, Switzerland,
the session considered the existing
building blocks inadequate in improving
the healthcare systems of lower and middle
income countries.
Published in 2010, the WHO “six
building blocks of health systems” cover:
1. Service delivery
2. Health workforce
3. Information
4.Medical products, vaccines and
technologies
5. Financing
6. Leadership and governance (stewardship)

In his summary, Kelley said, “It is clear
that the ‘six building blocks’…include
major action areas where the application
of improvement methods can achieve
significant results.”
However, common concern amongst
the Seminar contested that community
mobilization and patient perspective
should also be added to the existing list.
Reflecting on all the comments and
suggestions made through the group work
of the afternoon, Kelley added in his
summary:
“Though [its] a broad set of areas to
address, key lessons emerged that may
form the beginnings of an overarching
strategy to more explicitly link quality
and safety improvement to the larger
health systems strengthening effort.”
These key lessons included mobilizing
clients
and
reforming
financing
systems, strengthening quality in health
information systems and building the
healthcare workforce.

Making Health Care Better in Low and Middle Income Economies: Wednesday, April 25, 2012
What are the next steps and how do we get there?

FEATURED FELLOW

Dr. M. Rashad
F. Massoud
By: Louise Hallman
Trying to pin Dr. M. Rashad Massoud
down long enough for an interview is
no mean feat. The smiling Americanbased, British-educated Palestinian
doctor is seemingly always on the go.
The morning sessions start at 9am and
he might have been up until 1am, perfecting the next day’s line-up, updating
the e-conferencing website, or discussing the improvement of quality improvement with other participants into
the small hours, but the tiring schedule
never shows.
Dr. Massoud is no stranger to the Salzburg Global Seminar. Now chairing the
session ‘Making Health Care Better in
Low and Middle Income Economies:
What are the next steps and how do we
get there?’, Dr. Massoud first came to
Salzburg as a fellow in 2001.
A student of Don Berwick, the outgoing Administrator of the Centers for
Medicare and Medicaid Services and the
former president and CEO of Institute
for Healthcare Improvement in the USA,
Dr. Rashad attended a session on Patient
Safety and Medical Error. This first visit
to Schloss Leopoldskron convinced Dr.
Rashad of the value of the Seminar.
“The first seminar I came to,” Dr.
Massoud explains over a hastily poured
coffee, “followed the Institute of Medicine’s report ‘To Err is Human’ in which
medical errors were described as between
48,000 and 98,000 errors per year, half of
which are easily preventable. And what
[Don Berwick, session chair] did, because
safety was a poorly developed area generally speaking in healthcare, he brought in
experts from aviation, from space, from
road traffic accidents, from psychologists
to meet with people who are in the area of
improvement and that was the beginning
of a major thrust in patient safety today.
In fact some of the people who were here
in 2000 are today some of the leaders in
safety and healthcare. That was an amazing experience...
“The whole patient safety movement –
a lot of them were here and that’s how the
work started. The meeting here was cer-

tainly a significant milestone in the development of the safety effort in healthcare
and it really moved things forward.”
Dr. Massoud agrees he has similar high
hopes for his session this week.
“I’d really like us to take the opportunity of this magnificent setting,” he says
turning to look out of the Meierhof, across
the lake and to the Untersberg mountain.
“The environment we have, the focus
that we get out of having 60 people in the
same place – not just for the session but
for all the interactions outside of the sessions. Having been here already – these
interactions were even more valuable than
the formal sessions themselves.”
Indeed – Dr. Massoud is almost as great
an advocate of late night discussions in
the Schloss’ Bierstube as he is of improving healthcare.
“So if we can put all this together,” he
continues, “what I’d like to come out with
is a thoughtful way that all of us who are
representing different groups – host country national governments, improvement
efforts, representing implementers in the
field, donor agencies, other stakeholders – all of us should think through how
do we maximise and leverage everything
we have that would enable us to improve
healthcare in a different way, take the
healthcare improvement effort, which has
so far been very successful, to a whole
other level.”
The session itself has been two years
and dozens of hours of Skype conference
calls in the making and brings together
over 60 healthcare professionals, from
physicians, donors, improvement advocates, government officials to civil society
leaders, from over 35 countries.
“When John Lotherington [SGS Program Director for Health] approached me
with the idea of a seminar on improvement science…my idea was that we probably don’t need just another conference
or meeting to talk about it, however what
we could do is a strategy conversation –
something that would enable us to think
through what have we accomplished to
date, what are the challenges ahead and
design an agenda that would take us
through the next five to ten years. Everything followed from there. I invited partner organisations, colleagues to join the
planning committee. We started to think
through what would that agenda look like,
what are the themes we have to discuss,
who are the people we need to have in the
room?”
Much of this week’s session has fo-

Dr. M. Rashad F. Massoud
cussed on ‘Quality Improvement’, and
although the physician-cum-Director of
USAID’s Health Care Improvement Project is a strong advocate of the school of
thought (that more isn’t always better –
more resources, more money, more hospitals – and that healthcare professionals
should strive to deliver the best level of
care from the resources they have and
constantly improve upon that level of
care) he is not overly keen on the term.
“If there was one thing I could do here
it would be remove the word ‘quality’,”
he laughs.
“Everything we’re talking about here
is how can we ensure the patients get the
best outcomes possible. What is the best
medicine that we know? Can we deliver it
to them correctly so that they benefit maximally from this? Can we do this in ways
that are not wasteful and inefficient? Can
we be mindful about meeting patients’
needs and expectations? Improvement is
what we should be doing in the first place;
good quality care is what we should be
providing patients anyway.”
His enthusiasm for the topic is clear
from the outset, driving conversations
from the breakfast table first thing in the
morning, through the day’s sessions, right
up to in the Bierstube – the Seminar’s
own on-site bar – last thing at night.
“He’s like this all the time,” says
his research assistant, Nana Mensah
Abrampah. Dr. Massoud just laughs,
shrugs, and hurries off for another meeting.

Wednesday, April 25, 2012 Making Health Care Better in Low and Middle Income Economies:
What are the next steps and how do we get there?

HEAD TO HEAD

Patients’ needs and preferences
Can the two ever be the same?
Sparked by a debate that emerged when establishing the key challenges to healthcare improvement on Monday
afternoon, an addition to the program was made to air the views of participants on the matter of patients’ needs versus
their preferences. Are the two as diametrically opposed as they first appeared in Monday’s session? Can one exist
without the other? And can they ever be married together? Or should they always be considered separately?
Louise Hallman spoke to the two main discussants – Robinah Kaitiritimba and Pierre Barker – to try to establish
some of these answers.

‘Patients’ preferences’ is the choice that patients make
for different reasons and ‘patients’ needs’ is that which
is necessary. I think both of them are important. I think
patients’ preferences are extremely important and patients’
rights must be the most important thing. But I think it’s
important to consider circumstances.
Where patients’ cultures and traditions overrides the freedom
to make the kind of choice that would improve life. For instance,
woman in the process of childbirth and pregnancy have to make
certain because of what culture and traditions demand; you are
not allowed to say that you are pregnant…so that means that
women will not register with healthcare givers. It is considered
brave for a woman to give birth in alone in a room and not make
noise, even if she’s in pain.
So it’s extremely important that those kinds of circumstances
are considered in order to be able to serve the needs of patients.
We should begin to think about marrying the patients’ interests
and the choices they make. The right to choose should be proceed
by a lot of information and education and empowerment. The
right choice should be the informed choice.

We still have a lot of work to do, particularly in accessing
the needs of people deep in the community. So I think
we know what to do, although we don’t do it very well,
when patients come to see doctors and nurses, but I think
we are way behind in our ability to access and respond
to the needs of people in the community that are totally
determined by context and culture.
Preferences are culturally determined and needs are
medically determined. I think both are absolutely crucial
– I don’t think it’s an either/or issue. I think [patients’
preferences and patients’ needs] should always be
considered together. They both need to be addressed; it’s
just a question of how you design your response. You have
to be very thoughtful about both of them because the needs
are going to be addressed through patient education and
the preferences are going to be addressed through deep
engagement in community structures.
And then there’s the personal level; there are preferences
that are not totally culturally determined and they all need
to be addressed at the point of care.

Making Health Care Better in Low and Middle Income Economies:
What are the next steps and how do we get there?

Wednesday, April 25, 2012

Mozarts Geburtshaus, 9 Getreidegasse. The Mozart family lived here for 26 years, from 1747 to 1773. Wolfgang
Amadeus Mozart, was born here on January 27, 1756. It is now a museum and exhibits include Mozart’s child violin,
his concert violin, his clavichord, his harpsichord, portraits such as the unfinished oil painting “Mozart at the Piano”.

TALKING
POINT

What role does
consumer
choice have
in improving
healthcare in
lower and middle
income countries?

“

Consumers’ choice is
not really only related to
the individual’s choice but
it relates to the collective’s
choice. If the choice for the
collective consumer is limited
then an individual’s right to
choice ends where the rest of
the collectivity’s start.
Jorge Hermida, Director,
HCI Programs - Latin
American Region, URC,
Ecuador

”

“

I think it is fundamental
if you want to improve
healthcare, the quality of
healthcare, consumers’
choice is a key element. That
implies that first you have to
recognise that, and second
you have to give elements
to the people so that they
can make choices - giving
information, allowing them to
participants, empowerment.
This is not an easy thing to
do... If they have a choice in
selecting a physician for their
care, there are some areas
with only one physician so
they have no choice! ...But
you have to it. I see it as a
key element for pressing the
system to provide quality
health services. If that doesn’t
happen, the health system
won’t be as responsive as it
should be.
Enrique Ruelas, Senior
Fellow, Institute for
Healthcare Improvement,
Mexico

”

“

Consumers in most
circumstances have less
opportunities to make choices
about their healthcare. The
bulk of the population live
below the poverty line and in
the remote areas. It is not a
matter of choice for them but
rather a matter of access to
the nearest health facility...
In cities people have health
facilities but then again the
poorer tend to be going for
public hospitals and they
have limited choices. Those
with better socioeconomic
status and can afford better
and higher quality prices
for healthcare services, they
will go for private hospitals
because the perception is the
quality is better...
And then we have a small
percentage of people who
really can afford health
services outside the country.
Mirwais Amiri, Senior
Quality Improvement
Advisor, URC,
Afghanistan

”

“

The primary consumer
in healthcare is the patient.
So when we are talking
about low and middle
income countries, the only
way consumers’ choice can
even be an issue is when
affordability and access to
services are there. And before
there is affordability and
access, the only choice the
consumers have will be to
either live or die.
Ayman Sabae, Master’s
Student, International
Healthcare Management,
Innsbruck, Austria/Egypt

”

Got a question
you’d like to
have debated?
Tweet us!
@salzburgglobal

Making Health Care Better in Low and Middle
Income Economies: What are the next steps
and how do we get there?
Thursday, April 26, 2012

Salzburg global seminar
SALZBURG DIARIES
Hearts and minds for QI
By: Ezequiel García-Elorrio
On Wednesday the sun was shining and
the weather was very mild – the right
ambience for a critical discussion on
leadership, a key factor for every QI
initiative around the world.
Dr. Bruce Agins, Medical Director of the
New York State Department of Health AIDS
Institute chaired the morning session; his set
of panelists gave their views on the subject.
We first had the chance to listen to a
presentation from Rwanda’s Health Minister,
Dr. Agnes Binagwaho, about situational
leadership and the experience from local
initiatives; a very instructive description on how
to get things done in limited resource settings
and changing environments. She seemed like
a very committed and strong person, very
satisfied with the accomplishments so far.
We then participated in a panel discussion
where the panel’s views on leadership
prompted stimulating discussion.
One the things that was said and struck me,
was something said by Sir Liam Donaldson:
“We have to win the heads and win the
hearts” in order to succeed.
After the break we had a small group
discussion with the following topics:
1. How do leaders effectively carry out the
designing of and planning for quality?
2. How do leaders effectively engage
community in quality improvement efforts?
3. How do leaders effectively select
strategies to communicate initiatives and
results?
4. How do leaders implement coordinated
strategies at all levels of the public system?
5. How do leaders effectively implement
quality improvement efforts?
Several suggestions were made [please
read the online summary of the session]
and will also be incorporated in the final
document of the Session.
Two other comments that impacted me
were: “Please never give up” and “Quality
Improvement is an evolution not revolution”.
There was so much wisdom around.

Rwanda’s Minister of Health, Dr. Agnes Binagwaho joined panelists from
Namibia, Thailand, the UK, Uganda and the US to talk about leadership

SESSION OVERVIEW

“Leaders must never give up”
Wise words from Rwandan MoH
By: Louise Hallman
Participants at the Salzburg Global
Seminar were urged on Wednesday to
continue to strive for quality improvement
in healthcare by the Minister of Health for
Rwanda, Dr. Agnes Binagwaho.
Dr. Binagwaho joined the Seminar to speak
on ‘Strengthening Leadership and Policy for
Improving Care in Low and Middle Income
Economies’ via video link from Kigali. She
spoke on her own personal experiences of
leading quality improvement, particularly
highlighting the importance of engaging
all stakeholders, including the population,
in improving healthcare, as politicians like
herself rarely stay in office for more than two
years.
The session also saw an international panel
- from Namibia, Thailand, the UK, Uganda
and the US, as well as Rwanda - convene to
share their views and successful experiences
of leading healthcare improvements.
Community level engagement was brought

up repeatedly through out the session, with
participants during their breakout workshops
yet again drawing attention to the limitations in
traditional thinking. One of the key suggestions
to be made by Salzburg participants addressed
the need to lead change through all levels
of healthcare systems, not just national, but
regional, district and community.
Another suggestion was that leaders must
establish clear direction and set priorities
that are then communicated to the public,
championing transparency in performance
and displaying integrity in addressing those
promised priorities.
Session chair, Bruce Agins, highlighted
in his report: “As they stay attuned to their
environment and changing landscape, leaders
in particular need to stay attuned to the care
provided to those most vulnerable in their
nations and drive improvement to meet their
needs which may often require specific efforts
to ascertain.”
All suggestions made by the groups will be
incorporated into the Salzburg Statement.

Making Health Care Better in Low and Middle Income Economies:
What are the next steps and how do we get there?

Thursday, April 26, 2012

Sir Liam Donaldson presents the Swiss Cheese Model of Accident Causation. Presenting the case of Mamma Sessay, an 18-year-old mother in Sierre Leone, who died due to complications in labor with twins, Sir Liam proposed that
Mamma had been failed at several points and efforts were needed to “fill in the holes” to avoid future maternal mortailty.

TALKING
POINT
What is the
number one
most important
attribute for a
good leader to
have?

“A good team that can point
out the real priorities and
ensure the strategic ones are
being taken and put into the
agenda.
Tatiana Paduraru,
National Consultant
on Foreign Assistant,
Ministry of Health,
Moldova

”

“Tolerance...they have to

work with different donors and
organizations... It is important
for leaders to understand what
other people would like and
try to choose key issues.
Aigul Kalieva, Chief
of Neonatal Services,
Ministry of Health,
Kyrgyzstan

“A vision...chart out a path
and all other things will fall
into place.”
Charles Nde Awasom,

Medical Director, Ministry
of Health, Cameroon

“Insight...if a leader isn’t

able to learn from mistakes
and to support people when
mistakes are made, they will
never reach their potential for
delivery.
Tracey Cooper, President,
ISQua, Ireland

”

“Unflagging dedication and
commitment to the goal of
improvement.”
Bruce Agins, Medical
Director, AIDS Institute,
New York State
Department of Health,
USA

Making Health Care Better in Low and Middle
Income Economies: What are the next steps
and how do we get there?
Friday, April 27, 2012

Salzburg global seminar
SALZBURG DIARIES
Day of action
By: Ezequiel García-Elorrio
Pierre Barker from IHI chaired a very
interactive session on sustainability
on Thursday morning covering:
“Sustainability in not permanence
but integration into the culture of the
healthcare system”
To begin every participant scored on a
special designed matrix the way their own
country is doing on the different aspects of
QI effort implementation and dissemination.
The results were the aggregated.
We then explored different perspectives
that may help sustainability. They were:
Policy, funder and politician’s vision.
Alignment of managers and providers, data
system adoption, QI capacity needs, role of
the technical advisors and the role of the civil
society were also topics of discussion.
Some thoughts that come from it were:
1. Demand of quality from the civil society
is crucial to give continuity to QI efforts.
2. Tension within current needed systems
to collect data for the QI process.
3. Capacity of the community to improve
the demand from the civil society
4. Advisors had the challenge of
demonstrating the effectiveness of
the interventions specially whenever
communicating the to the outside world.
5. Harmonization and coordination of
donors is the will from the funder’s
perspective.
6. Politicians should include quality
as a national policy to give QI efforts
sustainability.
7. Developing a common language is
critical to create a policies across countries.
In the self-assessment of the countries
most of them fell in a category where that
so far mostly were in the middle of the river
or starting to cross it. Not the best scenario
but an opportunity to do it the right way
considering the gathered experience.
It’s been a busy morning and the best is
to come. Lots of ideas and suggestions are
consolidating for a productive closure session.

Preaching to the unconverted
“You may lose the battle, but
you won’t lose the war”
By: Louise Hallman
On the penultimate day of the Salzburg
Global Seminar on ‘Making Health
Care Better in Low and Middle Income
Economies: What are the next steps
and how do we get there?’, participants
were given a new set of commandments
to consider: ‘Ten Commandments for
Dealing with Politicians’.
Enrique Ruelas, Senior Fellow at the
Institute for Healthcare Improvement,
Mexico, shared his commandments
with the group as part of the Thursday
morning
session
on
‘Sustaining
Execution’ covering introducing QI
systems to countries unfamiliar with the
methodology and designing sustainability
into healthcare initiatives from the start.
Mr. Ruelas’ commandments offered
an insight into the psyche of politicians
and included selling the concept of QI in

healthcare to politicians, not arguing with
them, and also aligning your position with
existing initiatives. The full list can be
seen overleaf.
Reflecting on the morning’s session,
Bruce Agins, chair of the previous day’s
session on leadership said: “There clearly
is no one way to communicate the benefits
or importance of QI... One has to know
and read your audience to adapt your
message appropriately, i.e. scanning and
reading the environment effectively to
tailor and craft your message.”
As with previous sessions, all key
suggestions made by the group were
collated by the session chair to be
included in the final session to be held
on Friday morning entitled ‘Next Steps’.
Participants will not only reflect on the
outcomes of the week-long Session but
also produce a Salzburg Statement to be
shared with key stakeholder groups.

Making Health Care Better in Low and Middle Income Economies:
What are the next steps and how do we get there?

TALKING
POINT
What positive
outcome will you
take back to your
colleagues from
this session at
Salzburg Global
Seminar?

“That the patient matters and

quality improvement is all
about the patient.
Natalia Largaespada
Beer, Maternal and Child
Health Technical Advisor,
Ministry of Health, Belize

”

“Quality isn’t really my

field...I was confused, and
I guess I didn’t really grasp
the importance of quality or
the huge impact it has [until
now].
Michelle Vanzie, Director
of Policy Analysis and
Planning Unit, Ministry of
Health, Belize

”

“From this meeting I will

have a lot of friends! [I will

have] a lot of challenges. We
have discussed a lot of issues
on quality so when I go back,
I think my vision will be
different.
Babacar Ndoye, Coordinator, National
Program Against
Nosocomial Infections,
Ministry of Health, Senegal

”

“This meeting has brought

great light to ideas on what we
can share with our country, not
to show that QI is a program
but a science. I think we can
present, we can advocate to
leadership that this is the QI
methodology.
Januario Reis, Clinical
Site Monitoring Specialist,
USAID, Mozambique

”

“The one this is the validation

of the enthusiasm around
using quality improvement
to enhance the healthcare of
poor around the world and
create a quality movement to
really make great progress very
quickly in healthcare.
Sheila Leatherman,
Research Professor,
Gillings School of Public
Health, UNC, USA

”

Friday, April 27, 2012

THE 10 COMMANDMENTS
How to deal with politicians
1. Politicians always
think they know
best…because they
are politicians. Do
not make them feel
otherwise.
2. Politicians always
have great ideas…
although maybe their
ideas are the ones you
gave them.
3. Do not argue with
them…sell! Good
sellers always offer
a benefit first and
then the product as
concrete and clear as
possible.
4. Align your proposals
with other existing
initiatives to add
weight.
5. Bring on board as
many stakeholders
as possible, this
increases your power.
6. Show your power
but never say you
have it…that might
be interpreted as a

threat - politicians will
understand you have
it.
7. Expose the
laggards…but be kind.
8. Give visibility to what
you are doing.
9. Make quality
improvement an
inspiring cause to
be embraced…not an
argument or a method.
10. Pull, they will push.
The more you push,
the more resistance
you may create. The
more you pull, others
will want to join. Make
politicians feel that
the train is moving
and therefore, either
they jump in or be left
behind.
Finally, be very
enthusiastic, patient and
tenacious. Politicians
come and go. Your cause
will always be. You may
loose a battle but will never
loose the war.

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?
Session Report 489

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?
Session Report 489

ABOU T THE REP ORT CON TRIBU TORS:

Bruce Agins is a medical director for the New York State Department of Health AIDS Institute and oversees a staff
of 40, involved in HIV treatment guidelines development, quality management and education programs. He is the
principal architect of New York’s HIV Quality of Care Program and has 20 years of HIV-specific quality improvement
(QI) experience. He is principal investigator of HIVQUAL-US and the National Quality Center. He has participated as
faculty in national HIV QI Collaboratives and chaired the faculty of the national HIV QI Collaborative for state HIV
agencies. Dr. Agins is director of HEALTHQUAL International, an initiative to build capacity for QI globally. He has
extensive experience in the field of international QI and participated in consultations with WHO devoted to quality
management in resource-limited settings. He is a graduate of Haverford College and Case Western Reserve School of
Medicine and received an M.P.H. from the Mailman School of Public Health at Columbia University.

Pierre M. Barker is the senior vice president of the Institute for Healthcare Improvement (IHI) in Cambridge,
MA. He is responsible for IHI’s expanding portfolio of large-scale health systems improvement initiatives in lowand middle-income countries. Previously he served as senior advisor to IHI’s programs in Africa and India, and
as director of IHI’s South Africa projects. Dr. Barker, a pediatrician by training and a South African by birth, is a
renowned authority on improving health systems, particularly in the areas of maternal and child health and HIV/
AIDS care. Before joining IHI he was medical director of University of North Carolina Children’s Hospital clinics
and was responsible for leading health system-wide initiatives on improving access to care and chronic disease
management. He advises the WHO on health systems strengthening and redesign of HIV care and infant feeding
guidelines.

Louise Hallman is the editor at Salzburg Global Seminar, where she manages online and print editorial content as
well as other in-house journalism and marketing projects. In her role she creates, commissions and edits content for
SalzburgGlobal.org, manages social media platforms, contributes articles and features to external publications, and
liaises with visiting members of the press. Ms. Hallman holds Master’s degrees in international relations and Middle
East studies from the University of St. Andrews and multimedia journalism from Glasgow Caledonian University.
Prior to joining SGS in April 2012, she worked for WAN-IFRA as the manager and publication editor for the SIDAfunded ‘Mobile News in Africa’ project and the International Press Institute, as a press freedom advisor and in-house
journalist, where she focused on Latin America and Europe.

James Heiby is a medical officer in the Global Health Bureau of USAID in Washington, DC. On the basis of an
earlier 12-country quality assessment study, in 1990, he developed the first USAID project dedicated to addressing
quality of care issues in USAID-assisted countries. Since then, he has continued to lead the Agency’s program in
adapting modern quality improvement to the needs of health systems in lower- and middle income countries. The
current Health Care Improvement (HCI) Project is the fourth 5-year project in this program. Working with a number
of USAID country missions, the program has expanded from a $5 million annual budget initially, to over $30 million
under HCI, working in over 30 countries. Throughout this period, the program has included an expanding research
and evaluation component. Prior to joining USAID in 1978, Dr. Heiby served in the Bureau of Epidemiology of the
Centers for Disease Control in Atlanta. He received an M.D. from Johns Hopkins University in Baltimore and an
M.P.H. from the Harvard School of Public Health in Boston, and completed his clinical training at New York HospitalCornell Medical Center.

13

Making Health Care Better in Low and Middle Income Economies: What are the next steps and how do we get there?
Session Report 489

Edward Kelley serves as coordinator and head of strategic programs for WHO Patient Safety in Geneva,
Switzerland. In this capacity, he coordinates both strategic management and external relations and business
development for the world’s only global health care safety initiative, with responsibility for teams working in
health care associated infection, technology, capacity building, reporting and learning and patient and community
empowerment. Prior to joining WHO, Dr. Kelley directed the only ongoing national examination of health care
quality and disparities in the United States as the director of the US National Healthcare Reports for the US
Department of Health and Human Services in the Agency for Healthcare Research and Quality. He also directed
the 28-country Health Care Quality Improvement Project of the Organization of Economic Cooperation and
Development. Dr. Kelley’s research and project work has produced numerous publications in the areas of health
systems performance measurement and improvement, value for money in health care, cost and quality interactions
and the clinical areas of pediatric infectious disease, respiratory illness, cardiac care and cancer survival.

Sheila Leatherman is a research professor at Gillings School of Global Public Health, The University of North
Carolina. She conducts research and policy analysis globally, focusing on health care quality and health systems
reform, as well as the nascent field of integrating microfinance and community health programs as a strategy for
poverty reduction and improved health outcomes. She was elected to the Institute of Medicine at the US National
Academy of Sciences in 2002. Through research and policy advising, she has worked with Afghanistan, Australia,
Benin, Bolivia, Burkina Faso, Canada, Cambodia, India, Peru, Philippines, Singapore, South Africa, South Sudan,
Tanzania and the UK. She has published widely in the field of health care quality including national quality chart
books in the US, UK and Canada and articles in peer-reviewed literature on health policy, quality measurement and
health reforms. In 2007, she was awarded the honor of Commander of the British Empire by Queen Elizabeth for her
work over a decade as an independent evaluator of the impact of government reforms on quality of care in the NHS.

John Lotherington is a program director at Salzburg Global Seminar, with particular responsibility for the
Salzburg Global health care programs. Prior to that, he was director of the 21st Century Trust in London. He
began his career in history education and maintains an interest in that area. His publications as editor and author
include The Communications Revolution; Years of Renewal: European History 1470-1600; The Seven Ages of Life;
The Tudor Years; introductions to The Florentine Histories by Niccolo Machiavelli, The Book of the Courtier by
Baldassare Castiglione, and Inferno by Dante Alighieri. He is chair of the Foundation for Democracy and Sustainable
Development and a Fellow of Goodenough College in London.

Nana Mensah-Abrampah is an international public health professional. She is a quality improvement fellow
with the USAID HCI and collaborates closely with the director of the HCI Project on global health issues, including
program implementation, finance, health systems strengthening and quality improvement mechanisms. In
2011, she helped develop The Africa Consultative Workshop for Health Care Improvement, which was the first
of its kind in assessing how core competencies for quality improvement can be integrated into the education and
training of health workers in Africa. Ms. Mensah-Abrampah holds a B.Sc. in economics from the University of Mary
Washington. Her publications include “Improving the delivery of safe and effective healthcare in low and middle
income countries” (BMJ 2012) and “Key Steps in Improving Health Care: Technical Plenaries and Exercises” (USAID
HCI Project 2011).

14

M. Rashad Massoud is senior vice president for the Quality and Performance Institute and director of the
US Agency for International Development (USAID) Health Care Improvement (URC) Project in Washington, DC.
He served as senior vice president at the Institute for Healthcare Improvement (IHI), overseeing their strategic
partnerships - the key customers working with IHI on innovation, transformation and large scale spread. Dr.
Massoud joined URC in 1998, leading several improvement efforts around the globe, including working on
developing the World Health Organizationâ&#x20AC;&#x2122;s (WHO) strategy for design and scale-up of antiretroviral therapy to meet
the 3x5 target and large scale improvement in the Russian Federation. He also founded, and for several years led,
the Palestinian health care quality improvement effort. He was a founding member and chaired the multi-country
Quality Management Program for Health Care Organizations in the Middle East and North Africa and worked
as a medical officer with the United Nations Relief and Works Agency. Dr. Massoud has also consulted for and
collaborated with several NGOs, KPMG, UNICEF, the World Bank, USAID and WHO.

Sylvia Sax is an international public health consultant and lecturer in the Institute of Health at the University
of Heidelberg in Germany. She is currently providing consultancy support to governments in Kazakhstan on
upgrading their healthcare accreditation system, in Malawi on results based financing and in Kenya on healthcare
quality management. Her areas of expertise include healthcare quality management, healthcare accreditation,
health system strengthening, health provider motivation, and results based financing. She is a doctoral candidate
in the Institute of Public Health, University of Heidelberg, and received an M.P.H. from the University of Otago,
Christchurch, and a B.Sc. in nursing from the University of Illinois, Chicago.

www.salzburgglobal.org/go/489

Salzburg Global Seminar is grateful to the following
donors for their generous support of Session 489
University Research Co., LLC
Bill and Melinda Gates Foundation
GIZ
The Nippon Foundation
USAID
World Health Organization
Salzburg Global Seminar would like to thank the Session speakers for their assistance in
developing this program and for generously donating their time and expertise, and to all the
participants that contributed their intellectual capital and superior ideas.
FOR MORE INFORMATION CONTAC T:

John Lotherington

Astrid Koblmueller

Clare Shine

Program Director

Program Associate

Vice President and Chief Program Officer

jlotherington@salzburgglobal.org

akoblmueller@salzburgglobal.org

cshine@salzburgglobal.org
ÂŠ 2012

Salzburg Global Seminar
Salzburg Global Seminar was founded in 1947 by Austrian and American students
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